Dementia refers to a loss of cognitive function (an intellectual process resulting in an understanding, perception, or awareness of one's thoughts and ideas). Dementia can be caused by changes in the brain such as those associated with disease or trauma. The changes may occur gradually or quickly.

Cognition is the act or process of thinking, perceiving, and learning. Cognitive functions that may be affected by dementia include decision making, judgment, memory, spatial orientation, thinking, reasoning, and verbal communication. Dementia may also result in behavioral and personality changes, depending on the area(s) of the brain affected.

Dementia is actually a word for a group of symptoms caused by disorders that affect the brain. It is not a specific disease. Individuals with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose the ability to solve problems or control emotions and their personalities may change. These individuals may become agitated or hallucinate.

Dementia usually results from a widespread destruction of, or interference with, brain cells. Consequently, there is a loss of mental functions previously controlled by those cells.

Many different diseases can cause dementia, including Alzheimer's disease, Huntington's disease (an inherited movement disorder), and stroke (neurological damage due to a lack of oxygen to the brain). Drugs are available to treat some of these diseases. While these drugs cannot cure dementia or repair brain damage, they may improve symptoms or slow down the disease.

Dementia can be progressive, such as with Alzheimer's disease, or occur for a short period of time, perhaps as the result of a head injury.

Progressive dementia is most common among the elderly. These individuals are usually termed "senile." However, dementia should not be considered a part of the normal aging process. Most individuals who reach their elderly years do not develop dementia.

Some dementia is reversible and can be cured partially or completely with a doctor's treatment. The degree of reversibility often depends on how quickly the underlying cause is treated. Irreversible dementia is caused by an incurable condition (such as in Alzheimer's disease and Huntington's disease). Individuals with irreversible dementia are eventually unable to care for themselves and may require constant care.

Some types of dementia, such as Alzheimer's disease and Huntington's disease, have been linked to genetics. However, most cases of dementia are thought to involve multiple factors besides heredity, such as age, gender, and lifestyle choices.

An estimated two million people in the United States suffer from severe dementia and another one to five million people experience mild to moderate dementia. Approximately five to eight percent of individuals over the age of 65 have some form of dementia; the number doubles every five years over age 65.

Symptoms develop when the underlying condition, such as Alzheimer's disease or alcoholism, affects areas of the brain involved with learning, memory, decision-making, and language.

Memory impairment is often the first symptom to be noticed. An individual with dementia may be unable to remember ordinary information, such as their birth date, phone number, and address, and may be unable to recognize friends and family members.

There is a progressive decline in cognitive function, including decision making, judgment, orientation in time and space, problem solving, and verbal communication.

Behavioral changes may be found in eating, dressing, and toileting. Dementia patients may be unable to dress without help and become incontinent or lose the ability to control urine flow. Normal interests, such as hobbies and social groups, are abandoned. Routine activities, such as driving, grocery shopping, and housecleaning, are unable to be performed. Individuals with dementia also have changes in personality, such as inappropriate responses and lack of emotional control.

Trauma may cause prolonged or permanent changes in cognition, memory, emotions, or behavior.

Medical history: Taking a thorough medical history involves gathering information about the onset, duration, and progression of symptoms. Also, any possible risk factors for dementia, such as a family history of the disorder or other neurological diseases, past medical history (conditions or diseases), and drug use (prescription, recreational, and non-prescription), will be evaluated.

The American Psychiatric Association has established two generally accepted criteria for the diagnosis of dementia: (1) a decline in recent and past memory and (2) impairment of one or more of the following functions: language (aphasia or the misuse of words or inability to remember and use words correctly); motor activity (apraxia or unable to perform motor activities even though physical ability remains intact); recognition (agnosia or unable to recognize objects, even though sensory function is intact); and executive function (unable to plan, organize, and think abstractly). Symptoms often develop gradually and show a progressive deterioration in function.

Delirium: The doctor must distinguish between delirium and dementia. Delirium is a transient (occurring over a short period of time), acute mental disturbance that manifests as disorganized thinking and a decreased ability to pay attention to the external world. Delirium is often caused by infectious disease, brain tumor(s), poisoning, drug or alcohol intoxication or withdrawal, seizures, head trauma, and metabolic disorders. It is important to treat underlying conditions promptly, as they may be life-threatening or progressive if left untreated. Symptoms of delirium include disorientation related to person, place, and time, memory impairment, rambling (irrelevant, incoherent speech), and a reduced level of consciousness.

Pseudodementia: Pseudodementia, a type of severe depression that occurs mainly in elderly people, causes many older individuals to fear that their memory and other mental abilities are diminishing as they age, even if this is not the case. A doctor will determine if the individual is suffering from this condition. The cognitive changes that resemble dementia include slow motor movements and thinking and short-term memory loss. Individuals who are depressed may be apathetic and answer questions without attempting to provide the correct response. They may exhibit poor eye contact and little spontaneous movement.

Neuropsychological testing: Sometimes doctors undertake a more extensive assessment of memory, problem-solving abilities, attention spans, counting skills, and language. This is especially helpful in trying to detect dementias at an early stage. Doctors use formal psychological tests to determine if an individual's mental abilities are as expected for his or her age and education. The patterns of any mental deficits observed during neuropsychological testing can help doctors sort out possible causes of dementia.

A Mental status evaluation screens memory, problem-solving abilities, attention spans, counting skills, and language skills. Questions such as "what day is it today?" or "who is the president of the United States?" may be asked. Recall tests are another example. Doctors may list familiar objects and then ask a person to repeat them immediately and again five minutes later. The Clock Drawing Test, the Mini-Mental State Examination (MMSE), and the Functional Assessment Staging (FAST) are commonly used mental status evaluation tools for determining if Alzheimer's disease or dementia are present.

Brain scans: Doctors may want to take a picture of the brain using a brain scan. Several types of brain scans are available, including computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, and positron emission tomography (PET) scan. Doctors can pinpoint visible abnormalities in the brain using these imaging techniques.

Genetic testing: Huntington's disease is diagnosed by analyzing DNA in the blood sample to determine if the gene exists for that condition. Huntington's disease is due to a single gene on chromosome 4. If someone has Huntington's disease he/she has a 50% chance of passing that gene to his/her children, causing the development of the disease.

Similarly, an analysis of DNA in the blood sample may reveal the ApoE4 gene, which is found in about one-third of Alzheimer's disease patients. However, until preventative treatment is available, testing an asymptomatic patient for APOE is not recommended. Clinical testing is also available for the PS1 gene, which accounts for many cases of the disease.

Complications depend on the underlying cause of the dementia. Complications include loss of ability to function or care for self, verbal and physical abusiveness to loved ones, loss of ability to interact, increased infections anywhere in the body, reduced life span, abuse by an overstressed caregiver, side effects of medications used to treat the disorder, and depression (common in patients with Alzheimer's disease).

Infections: In severe and advanced dementia, individuals may lose all ability to care for themselves. This can make them more prone to additional health problems such as pneumonia, which is a bacterial infection of the lungs and respiratory system. The individual may have difficulty swallowing food and liquids, which may cause them to aspirate (inhale) some of what they eat and drink into their airways and lungs, which may lead to pneumonia.

Urinary incontinence may require the placement of a urinary catheter, which increases the risk of urinary tract infections. Untreated urinary tract infections can lead to more serious, life-threatening infections.

Falls and their complications: Individuals with dementia may become disoriented, increasing their risk of falls. Falls can lead to bone fractures that require hospitalization, medications, and surgery, increasing symptoms of dementia such as confusion and agitation. In addition, falls are a common cause of serious head injuries, such as brain hemorrhage (bleeding in the brain). Prolonged immobilization after surgery and hospitalization may also increase the risk of a pulmonary embolism (blood clot in the lungs), which can be life-threatening.

In some cases, the appropriate treatment for the underlying condition can resolve dementia completely or partially. The type of treatment depends on the condition. For example, antibiotics are used to treat infection and surgery is performed to remove a blood clot or tumor.

Cholinesterase inhibitors: The U.S. Food and Drug Administration (FDA) has approved two classes of drugs to treat cognitive symptoms of dementia including Alzheimer's disease. The first to be approved were cholinesterase inhibitors, which increase the amount of the brain chemical acetylcholine. The three most commonly prescribed cholinesterase inhibitors include donepezil (Aricept®), rivastigmine (Exelon®), and galantamine (Razadyne®). Tacrine (Cognex®), the first cholinesterase inhibitor, was approved in 1993 but is rarely prescribed today because of associated side effects, including possible liver damage. About half of the people who take cholinesterase inhibitors experience a modest improvement in cognitive symptoms. Side effects include diarrhea, vertigo (dizziness), drowsiness, fatigue (extreme tiredness), nausea, and vomiting. Individuals with liver disease, peptic ulcer disease, chronic obstructive pulmonary disease (COPD), and bradycardia (slow heartrate) should not take these drugs.

Memantine: Memantine (Namenda®) is a drug approved by the FDA for treatment of moderate to severe Alzheimer's disease. Memantine is classified as an uncompetitive low-to-moderate affinity N-methyl-D-aspartate (NMDA) receptor antagonist, the first Alzheimer's drug of this type approved in the United States. It appears to work by regulating the activity of glutamate, one of the brain's specialized messenger chemicals involved in information processing, storage, and retrieval. Glutamate plays an essential role in learning and memory by triggering NMDA receptors to allow a controlled amount of calcium to flow into a nerve cell, creating the chemical environment required for information storage. Excess glutamate, on the other hand, over stimulates NMDA receptors to allow too much calcium into nerve cells, leading to disruption and death of cells. Memantine may protect cells against excess glutamate by partially blocking NMDA receptors.
Side effects include headache, constipation, confusion, and dizziness.

Other medications: Medications may be needed to treat the neurobehavioral symptoms associated with dementia. These symptoms interfere with normal daily activities and sleeping. Depression that occurs during the early stages are commonly treated with antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs) including fluoxetine (Prozac®) and sertraline (Zoloft®), and the tricyclic antidepressants (TCAs), including amitriptylline (Elavil®). Side effects include drowsiness, fatigue, and sedation. TCAs may increase mental confusion. Agitation may be treated with antipsychotic medications, such as haloperidol (Haldol®), risperidone (Risperdal®), olanzapine [Zyprexa®), and quetiapine (Seroquel®). Antipsychotics are not FDA-approved to treat symptoms of dementia and may increase the risk for death in elderly dementia patients. Side effects include sedation, confusion, and tardive dyskinesia (a movement disorder characterized by lip smacking, facial grimacing, and unsteady gait).

Long-term care: An individual with dementia may need monitoring and assistance at home or in an institution. Options include in-home care, boarding homes, adult day care, and convalescent or long-term care facilities (nursing homes).

Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may help a family care for a patient with dementia. In some communities, support groups may be available. Family counseling can help family members cope with home care.

In any care setting, there should be familiar objects and people. Lights can be left on at night to reduce disorientation. The activity schedule should be simple. Behavior modification may help some people to control unacceptable or dangerous behavior. This consists of rewarding appropriate behaviors and ignoring inappropriate ones (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may also help reduce disorientation.

Advance directives, power of attorney, and other legal actions may make it easier to decide about the care of the person with dementia. Legal advice should be sought early in the course of the disorder, before the person with dementia is unable to make such decisions.

Prognosis: The outcome of dementia varies. Dementia usually gets worse and often results in a decreased quality of life and decreased life span. Patients may survive eight to 10 years with Alzheimer's disease. Some have been known to live 25 years with the disease. Death usually occurs due to secondary infections (including pneumonia), heart disease, or malnutrition.

Ginkgo: Ginkgo biloba has been used medicinally for thousands of years. The scientific literature overall does suggest that ginkgo may benefit people with dementia (multi-infarct and Alzheimer's type), and may be as helpful as acetylcholinesterase inhibitor drugs such as donepezil (Aricept®). Well-designed research comparing ginkgo to prescription drug therapies is needed.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Good scientific evidence:

Aromatherapy: Aromatherapy is the use of essential oils from plants for healing purposes. There is suggestive preliminary evidence that aromatherapy using essential oil of lemon balm (Melissa officinalis) may effectively reduce severe agitation in dementia when applied to the face and arms twice daily. Other research reports that steam inhalation of lavender aromatherapy may have similar effects. However, there is a conflicting study that reports no benefits of aromatherapy using lemon balm, Lavender officinalis, sweet orange (Citrus aurantium), or tea tree oil (Malaleuca alternifolia). Overall, the evidence does suggest potential benefits. It is not clear if this is because of anxiety-reducing qualities of these therapies. Additional study is necessary. There is also preliminary research suggesting that aromatherapy used with massage may help to calm people with dementias who are agitated. However, it is not clear if this approach is any better than massage used alone.

Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine (medicine practiced in India) and is widely used in India for enhancing memory, pain relief, and treating epilepsy. Although bacopa is traditionally used in Ayurvedic medicine to enhance cognition, high-quality clinical trials are lacking. Two methodologically weak studies found some evidence that bacopa improves cognition. However, more high-quality and independent research is needed before bacopa can be recommended for enhancing brain function in adults or children.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously
with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Ginkgo: Multiple clinical trials have evaluated ginkgo for a syndrome called cerebral insufficiency. This condition, more commonly diagnosed in Europe than the United States, may include poor concentration, confusion, absent-mindedness, decreased physical performance, fatigue, headache, dizziness, depression, and anxiety. It is believed that cerebral insufficiency is caused by decreased blood flow to the brain due to clogged blood vessels. Some studies report benefits of ginkgo in patients with these symptoms, but most have been poorly designed without reliable results. Better studies are needed before a conclusion can be made.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Music therapy: Music is used to influence physical, emotional, cognitive and social well-being and improve quality of life for healthy people as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In people with Alzheimer's dementia and other mental disorders in older adults, music therapy has been found to reduce aggressive or agitated behavior, improve mood, and improve cooperation with daily tasks such as bathing. Music therapy may also be beneficial for dementia-associated neuropsychiatric symptoms, such as depression and aggressive behavior. Music therapy may help maintain mental performance in elderly adults undergoing surgical procedures, reduce postoperative confusion and delirium, and increase energy levels.

Music therapy is generally known to be safe.

Unclear or conflicting scientific evidence:

Acupressure, shiatsu: Acupressure may decrease verbal and physical agitated behavior in dementia patients. Further study is needed before a conclusion can be made.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Acupuncture has been reported to help improve memory and cognitive performance in the elderly. However, there is currently insufficient available evidence for the use of acupuncture in cognitive disorders and communication disorders. There is also insufficient evidence to recommend the use of acupuncture in the treatment of vascular dementia. More research is necessary.

Needles must be sterile in order to avoid disease transmission.Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Arginine: There is not enough information available to make a strong recommendation about the use of the amino acid arginine in senile dementia.

Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. The aesthetic aspect of the creation of art is thought to lift one's mood, boost self-awareness, and improve self-esteem. Art therapy also allows the opportunity to exercise the eyes and hands, improve eye-hand coordination, and stimulate neurological pathways from the brain to the hands. Art therapy may be an effective means of improving quality of life in the elderly. Art therapy has been used in only a few studies with Alzheimer's disease (AD) patients, with some suggestion of benefit in alleviating negative emotions and minimizing problematic behaviors. However, further studies are needed for definitive conclusions. There is evidence that the non-directed use of visual art (pictures) as a means of encouraging communication among elderly nursing home residents may increase well-being. It may also reduce blood pressure and improve medical health status with regard to reported dizziness, fatigue, pain, and use of laxatives.

Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.

Ayurveda: The herb Brahmi (Bacopa monnieri) is used in many Ayurvedic preparations for a variety of ailments. There is evidence from well-designed studies that it may improve memory and cognitive function in adults. Another study suggests that the herbal preparation Maharishi Amrit Kalash (MAK) -4 may enhance attention capacity or alertness, and thus reverse some of the detrimental cognitive effects of aging. Further research is needed to confirm these results.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long period of time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs may interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before use. Use guggul cautiously with peptic ulcer disease. Patients should avoid sour food, alcohol, and heavy exercise with use of this herb. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia chebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine and is widely used in India for enhancing memory, pain relief, and treating epilepsy. However, additional study is needed before a firm conclusion can be drawn.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously
with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents, or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Beta-carotene: Antioxidants such as beta-carotene may be helpful for increasing cognitive performance and memory. Long-term, but not short-term, beta-carotene supplementation appears to benefit cognition.

Avoid if sensitive to beta-carotene, vitamin A, or any other ingredients in beta-carotene products.

Black tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory enhancement. It remains unclear if tea is beneficial for this use. Limited, low-quality research also reports that the use of black tea may improve mental performance/alertness and cognition.

Black tea contains caffeine, which is a stimulant. Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.

Boron: Preliminary human studies report better performance on tasks of eye-hand coordination, attention, perception, short-term memory, and long-term memory with the use of boron. Although boron has not been studied in AD, it may be beneficial in improving cognitive function.

Bupleurum: In early study, an herbal combination formula containing bupleurum has been used as a treatment for minimal brain damage in children. Additional research is needed as results are inconclusive.

Avoid if allergic or hypersensitive to bupleurum, members of the Apiaceae or Umbelliferae (carrot) families, snakeroot, cow parsnip, or poison hemlock. Use cautiously if operating motor vehicles or hazardous machinery. Use cautiously with low blood pressure, diabetes, or edema. Use cautiously with a history of bleeding, hemostatic disorders, or drug-related hemostatic disorders. Use cautiously if taking blood thinners. Avoid if pregnant or breastfeeding.

Chromium: Early research suggests that chromium picolinate may help improve cognitive function in the elderly. Further study is needed in this area.

Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke, and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Coenzyme Q10: Coenzyme Q10, or CoQ10, is produced by the human body and is necessary for the basic functioning of cells. Promising preliminary evidence suggests that CoQ10 supplements may slow down, but not cure, dementia in people with Alzheimer's disease. Additional well-designed studies are needed to confirm these results before a firm conclusion can be made.

Allergy associated with coenzyme Q10 supplements has not been reported in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin or warfarin), blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.

Copper: Copper is a mineral that occurs naturally in many foods including vegetables, legumes, nuts, grains and fruits, as well as shellfish, avocado, and beef (organs such as liver). Conflicting study results report that copper intake may either increase or decrease the risk of developing Alzheimer's disease. Additional research about its effectiveness for Alzheimer's disease prevention is needed.

Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6mg/L. Use cautiously with anemia, arthralgias, and myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The United States Recommended Dietary Allowance (RDA) is 1,000?g for pregnant women. The United States Recommended Dietary Allowance (RDA) is 1,300?g for nursing women.

Cranberry: Preliminary study results show that cranberry juice may increase overall memory enhancement. Further well-designed clinical trials are needed to confirm these results. It is best not to use sweetened cranberry juice or cranberry juice cocktail due to the high sugar content. The use of 100% cranberry juice products is recommended by healthcare providers.

Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

Creatine: Early studies show that creatine may improve memory in certain populations, such as vegetarians and the elderly. Further research is required before recommendations can be made.

Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix®)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or with a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

DHEA: Dehydroepiandrosterone (DHEA) is an endogenous hormone (made in the human body) and secreted by the adrenal gland. DHEA serves as precursor to male and female sex hormones (androgens and estrogens). DHEA levels in the body begin to decrease after age 30 and may need to be taken as supplements. Preliminary evidence, from a controlled trial and a case series, gives conflicting results as to whether DHEA offers benefit to individuals with dementia. Well designed clinical trials, with appropriate endpoints are required before recommendations can be made.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Folate: Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Preliminary evidence indicates that low folate concentrations may be related to Alzheimer's disease. Well-designed clinical trials of folate supplementation are needed before a conclusion can be drawn.

Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of the fetus developing a defect. Folate is likely safe if breastfeeding.

Gingko: There is preliminary research showing small improvements in memory and other brain functions with use of ginkgo in patients with age-associated memory impairment (AAMI), although some studies disagree. Overall, there is currently not enough clear evidence to recommend for or against ginkgo for this condition. It remains unclear if ginkgo is effective for memory enhancement in healthy patients. Further well-designed research is needed as existing study results conflict.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Ginseng: Early small studies report that Fuyuan mixture, an herbal combination that contains ginseng, may improve symptoms of multi-infarct dementia. The effects of ginseng alone are not clear, and no firm conclusion can be drawn. In addition, the use of ginseng for mental performance has been assessed using standardized measurements of reaction time, concentration, learning, math, and logic. Benefits have been seen both in healthy young people and in older ill patients. Effects have also been reported for the combination use of ginseng with Ginkgo biloba. However, some negative results have also been reported. Therefore, although the sum total of available scientific evidence does suggest some effectiveness of short-term use of ginseng for mental performance, better research is necessary before a strong recommendation can be made.

Avoid ginseng with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Gotu kola: Ayurveda regards gotu kola (Centella asiatica) as an important rejuvenating herb for nerve and brain cells, believed to be capable of increasing intelligence, longevity, and memory. Asiaticoside derivatives, including asiatic acid and asiaticoside, were shown to reduce hydrogen peroxide-induced cell death, decrease free radical concentrations, and inhibit beta amyloid cell death in vitro, suggesting a possible role for gotu kola in the treatment and prevention of Alzheimer's disease and beta amyloid toxicity. Limited available clinical study investigated a combination product containing gotu kola on cognitive function in the elderly, but did not find any benefit. Additional study is needed to confirm these findings.

Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.

Grapeseed: Grape seed oil is a popular (non scented) carrier oil used in aromatherapy. Although grape seed has been compared to lavender oil and thyme oil to reduce agitation in dementia patients, there is not enough scientific evidence to make a conclusion about its effectiveness.

Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid with disorders that increase the risk of bleeding or with active bleeding disorders (stomach ulcers, bleeding into the brain, etc.). Avoid if pregnant or breastfeeding.

Green tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory and cognition. It remains unclear if tea is beneficial for this use. Limited, low-quality research reports that the use of green tea may improve cognition and mental performance/alertness.

Green tea contains caffeine, which is a stimulant. Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.

Guarana: Guarana is a native species of South America and has stimulating properties when taken by mouth. Guarana is also used to enhance athletic performance and to reduce fatigue. Guarana has not been shown to alter cognitive enhancement or arousal in preliminary studies. Caffeine found in guarana may improve simple reaction time, but may not improve immediate memory. Additional study is needed in this area.

Avoid if allergic/hypersensitivite to guarana (Paullinia cupana), caffeine, tannins, or species of the Sapindaceae family. Avoid with hypertension, psychological or psychiatric disorders, liver impairment, and arrhythmias. Avoid with other stimulatory agents, especially ephedra. Use cautiously with breast disease, impaired kidney function, diabetes, pre-existing mitral valve prolapse, iron deficiency, gastric or duodenal ulcers, bleeding disorders, glaucoma or if at risk for osteoporosis. Use cautiously if undergoing electroconvulsive therapy (ECT). Avoid if pregnant or breastfeeding.

Guided imagery: The term guided imagery may be used to refer to a number of techniques, including metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Early research suggests that guided imagery of short duration may improve working memory. Further research is needed before a firm conclusion can be drawn.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. In patients feeling unusually anxious while practicing guided imagery, or in patients with a history of trauma or abuse, a qualified health care provider should be consulted before practicing guided imagery.

Jasmine: Odors and memory improvement are considered to be somehow linked in the brain. Two clinical trials using weakly jasmine-scented rooms found that subjects did not have improved recall of a physical environment without the jasmine odor trigger but could remember a word list better when exposed to a jasmine trigger. More research is needed in this area.

Use cautiously during pregnancy, based on traditional use. Use cautiously in patients allergic to jasmine, jasmine oil, or other fragrances. Use cautiously during lactation as jasmine flowers applied to the breasts have been used as a lactofuge. Avoid oral consumption of essential oils, including jasmine essential oil, as they are extremely potent and can be poisonous.

Jojoba: Jojoba oil is traditionally used as a carrier or massage oil. There is currently not enough available evidence to recommend for or against the use of jojoba oil for dementia.

Avoid if allergic or hypersensitive to jojoba, its constituents, or members of the Simmondsiaceae family. Avoid oral consumption of jojoba products. Avoid if pregnant or breastfeeding.

Khat: Khat is a flowering evergreen plant that has been grown for use as a stimulant for centuries. Khat has been evaluated for its benefits for cognitive function; however, the results are mixed with some studies showing benefit and others showing negative effects. Additional study is needed to clarify these findings.

When taken by mouth, it is unknown whether khat is physically addictive. However, it is linked to psychological dependence and is illegal in the United States. Avoid if allergic to the Celastraceae family (staff vine family). Use cautiously if taking amoxicillin, ampicillin or stimulants. Use cautiously with a history of high blood pressure, fast heartbeat (tachycardia), depression, or motor tics (Tourette's syndrome). Avoid with glaucoma or mental illness. Avoid driving or operating heavy machinery after using khat. Avoid holding khat in the cheek for a long time. Avoid if pregnant or breastfeeding.

Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Breathing exercises are an important part of Kundalini yoga. There is some evidence from studies with healthy volunteers that use of certain breathing techniques (such as breathing solely through one nostril or the other) may improve different aspects of cognitive function. More studies are needed to determine if these techniques can reliably be used to improve cognitive function and possibly aid in treating cognitive and nervous system disorders.

Avoid exercises that involve stoppage of breath, with heart or lung problems, insomnia, poor memory, or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini Yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Lamaze techniques are based on yogic breathing. If started early in the pregnancy, it may be possible to master the ability of breathing to reduce stress and aid in labor. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.

Lavender: Small studies of patients with severe dementia in nursing homes have found that lavender aromatherapy or pinning a cloth to the patient with lavender oil on it may help to decrease agitated behavior. Although lavender is a sedative-type aroma, use during recess periods in a work environment after accumulation of fatigue seemed to prevent deterioration of cognitive performance in subsequent work sessions. Small trials investigating the effects of lavender aromatherapy on agitation and behavior in patients with Alzheimer's dementia report conflicting results. Further well-designed studies are needed before a conclusion can be drawn.

Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

L-Carnitine: Early evidence suggests the effectiveness of L-carnitine and/or acetyl-L-carnitine for Alzheimer's disease. However, the evidence is mixed. Most of the studies related to dementia suffer from various weaknesses. Although preliminary evidence is promising, there is insufficient available evidence to recommend for or against this use. There are also a limited number of studies relevant to the use of carnitine for memory. Carnitine does not appear to have any effect on memory. Additional study is needed before a conclusion can be made.

Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Lemon balm: Limited data is available supporting the use of lemon balm as a treatment for agitation in dementia patients. Additional study is necessary before a conclusion can be drawn. Clinical data suggest that the use of standardized lemon balm (Melissa officinalis) extract has some effect on particular self-reported measures of mood and cognitive performance. More rigorous studies need to be conducted using patient-relevant outcomes to better assess the validity of these results as they apply to patient care.

Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of lemon balm cream suggested minimal side effects for up to 10 days of application. Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.

Macrobiotic diet: Macrobiotics is a predominantly vegetarian, whole-foods diet that emphasizes whole grains (especially brown rice), vegetables, fruits, legumes, and seaweeds. The evidence is mixed as to whether or not a macrobiotic diet helps, hinders, or has no effect on cognitive function in children.

There is a risk of nutrition deficiencies with use of an exclusive macrobiotic diet; however, this can be avoided with appropriate menu planning. Use cautiously with cancer or other medical conditions without expert planning or supplementation. Macrobiotic diets are not recommended in children or adolescents without professional guidance or appropriate supplementation, and are also not recommended in pregnant or lactating women due to potential deficiencies, unless properly supplemented.

Massage: Massage with or without essential oils has been used in patients with dementia in chronic care facilities to assess effects on behavior. There is compelling early evidence that aromatherapy with essential oils may reduce agitation in patients with dementia, although the effects of massage itself are not clear.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Meditation: Some forms of meditation may have positive effects on cognitive function. However, there is not enough clear evidence that any specific form of meditation can support or enhance cognitive function.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Melatonin: Melatonin is a naturally occurring hormone that helps regulate sleep/wake cycles (circadian rhythm). There is limited study of melatonin for improving sleep disorders associated with Alzheimer's disease (including nighttime agitation or poor sleep quality in patients with dementia). It has been reported that natural melatonin levels are altered in people with Alzheimer's disease, although it remains unclear if supplementation with melatonin is beneficial. Further research is needed in this area before a firm conclusion can be reached.

Based on available studies and clinical use, melatonin is generally regarded as safe in recommended doses for short-term use. Melatonin should be avoided in patients using warfarin, and possibly in patients taking other blood-thinning medications or with clotting disorders. Melatonin may cause drops in blood pressure. Caution is advised in patients with high cholesterol levels, atherosclerosis, those at risk for cardiovascular disease, diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Mild gastrointestinal distress commonly occurs, including nausea, vomiting, or cramping. Patients with glaucoma taking melatonin should be monitored by a healthcare professional. Melatonin should be avoided in women who are pregnant or attempting to become pregnant; high levels of melatonin during pregnancy may increase the risk of developmental disorders. In men, decreased sperm motility and decreased sperm count are reported with use of melatonin.

Music therapy: Music therapy may reduce feelings of agitation and anxiety in patients with moderately severe and severe Alzheimer's disease. More research is needed to confirm these results.

Music therapy is generally known to be safe.

Niacin: Dementia can be caused by severe niacin insufficiency, but it is unclear whether variation in intake of niacin in the usual diet is linked to Alzheimer's disease (AD) or cognitive decline. Further research is needed before a conclusion can be drawn.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, or linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

Pet therapy: In the institutionalized elderly, there is evidence that pet therapy may reduce depression and blood pressure, reduce irritability, reduce agitation, and increase social interaction. In Alzheimer's dementia, there is evidence that the presence of a companion animal may increase social behaviors such as smiles, laughs, looks, leans, touches, verbalizations, or name-calling.

Avoid if allergic to animal dander. Use only animals that have had veterinary screening, particularly in situations involving young children, frail elderly, or patients with immune disorders or medical conditions making them vulnerable to infection. Do not provide unsupervised use of animals with the severely mentally ill and very young children. Avoid with a fear of animals or traumatic history with animals.

Physical therapy: Various physical therapy approaches, including activity-specific exercise programs, resistance training, and other physiotherapy or motor interventions have been studied for elderly patients with cognitive impairment, Alzheimer's disease, or related dementia. Physical therapy has also been studied for brain injury, nerve disorders, neurological disorders, and geriatric rehabilitation. Healthcare providers may suggest home-based physical therapy or similar exercise programs for patients with cognitive impairment. Overall, results are mixed and more high quality research is needed in this area.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed healthcare provider before initiation.

Policosanol: The effects of policosanol supplementation on reactivity and related brain activity have been examined. Although there is early compelling evidence, further research is necessary before a clear conclusion can be made.

Avoid if allergic or hypersensitive to policosanol. Use cautiously if taking aspirin or blood pressure medications. Use cautiously with high blood pressure. Use cautiously if pregnant or breastfeeding.

Polypodium leucotomos extract and anapsos: Extracts of the polypodium fern have been used for many health conditions. It is commonly found in South America and Europe. The South American species Polypodium leucotomos L. is also known as "calaguala." Extracts of this species are called "anapsos." Limited scientific information is available about the effectiveness of polypodium in the treatment of dementia and Alzheimer's disease.

Avoid if allergic or hypersensitive to ferns from the family Polypodiaceae. Use cautiously with heart disease or with use of blood pressure drugs. Avoid operating any heavy machinery when taking polypodium. Avoid if pregnant or breastfeeding.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Psychotherapy may improve language proficiency in children, and individual therapy may be more successful than group therapy. Further research is needed in this area.

Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

Reiki: Early research suggests that Reiki therapy may improve behavioral and memory problems in patients with mild cognitive disorders or mild Alzheimer's disease. However, additional studies are needed to confirm these findings.

Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.

Rhodiola: Early human study suggests that rhodiola may benefit learning, memory, and mental performance. Well-designed studies are needed before a recommendation may be made.

Avoid if allergic or sensitive to Rhodiola. Use cautiously in people with diabetes, cardiovascular disease, or neurological or psychiatric disorders. Rhodiola is not recommended for use during pregnancy or breastfeeding.

Rhubarb: Preliminary study has investigated rhubarb along with other herbs in the treatment of age-associated memory impairment (AAMI). Studies of rhubarb alone are needed to discern rhubarb's effect on aging and memory.

Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

Riboflavin: Adequate nutrient supplementation with riboflavin (vitamin B2) may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins including riboflavin has been reported to improve scores of depression and cognitive function in patients taking tricyclic antidepressants. This may be related to tricyclic-caused depletion of riboflavin levels.

Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as safe during pregnancy and breastfeeding. The U.S. Recommended Daily Allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women, and is 1.4 milligrams daily (1.6 milligrams for breastfeeding women).

Sage: Sage has long been suggested as a possible therapy for memory and cognitive improvement. Several trials provide evidence for the use of sage for this indication. Early evidence also suggests that sage oil may be useful in the treatment of Alzheimer's disease. Additional study is needed to confirm these findings and determine the best dose.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae (mint) family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.

Soy: It is unclear if soy isoflavone supplementation in postmenopausal women may improve cognitive function. Results from studies are mixed.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy.

TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. TENS is often used to treat pain, as an alternative or addition to pain medications. Preliminary research suggests that TENS may be of benefit with some symptoms of Alzheimer's disease, including mood, memory, and cycles of daily rest and activity. Additional human study is necessary before a firm conclusion can be drawn.

Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

Therapeutic touch: Studies suggest that therapeutic touch may reduce behavioral symptoms of dementia such as searching and wandering, tapping and banging, anxiety, agitation, and vocalization in people with Alzheimer's dementia. Well-designed studies are needed before a firm conclusion can be drawn.

Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

Thiamin: Because thiamin deficiency can result in a form of dementia (Wernicke-Korsakoff syndrome), its relationship to Alzheimer's disease and other forms of dementia has been investigated. Whether thiamin supplementation is of benefit in Alzheimer's disease remains controversial. Further evidence is necessary before a firm conclusion can be reached.

Thiamin is generally considered to be safe and relatively nontoxic. Avoid if allergic or hypersensitive to thiamin.
Rare hypersensitivity/allergic reactions have occurred with thiamin supplementation. Skin irritation, burning, or itching may rarely occur at injection sites. Large doses may cause drowsiness or muscle relaxation. Use cautiously if pregnant or breastfeeding.

Traditional Chinese medicine: Traditional Chinese medicine (TCM) herbal combinations have been used for the treatment of dementia and reportedly improve cognitive function and activities of daily living. More studies of better design are needed before recommendations can be made.

Acupuncture is generally considered safe. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurologic disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Turmeric: Curcumin has been shown to have antioxidant and anti-inflammatory properties and to reduce beta-amyloid and plaque burden in lab studies. However, there is currently not enough evidence to suggest the use of curcumin for cognitive function.

Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood-thinners, such as warfarin (like Coumadin®), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

Vitamin B12: Some patients diagnosed with Alzheimer's disease have been found to have abnormally low vitamin B12 (cyanocobalamin) levels in their blood. However, vitamin B12 deficiency itself often causes disorientation and confusion and thus mimics some of the prominent symptoms of Alzheimer's disease. Well-designed clinical trials are needed.

Avoid vitamin B12 supplements if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.

Vitamin E: Vitamin E has been proposed and evaluated for the prevention or slowing of dementia (including Alzheimer's type), based on antioxidant properties and findings of low vitamin E levels in some individuals with dementia. There is some evidence that all-rac-alpha-tocopherol (synthetic vitamin E) is similar in effects to a commonly used drug for AD, selegiline (Eldepryl®), in slowing cognitive function decline in patients with moderately severe Alzheimer's disease. No additive effect was observed when used in combination with selegiline. Retrospective data suggests that long-term combination therapy with donepezil (Aricept®) may help slow cognitive decline in patients with Alzheimer's disease. Overall, the evidence remains inconclusive in this area. Other research suggests that vitamin E from dietary sources or supplements does not affect the risk of developing Alzheimer's disease or vascular dementia.

Vitamin E may cause bleeding, especially in sensitive individuals such as those taking medications for bleeding disorders (including warfarin or Coumadin®). Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid use above the recommended daily level in pregnant and breastfeeding women.

Yoga: There is limited human study of yoga for memory improvement and mental retardation in children. Better studies are needed before a conclusion can be made.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Fair negative scientific evidence:

Beta-carotene: Intake of dietary or supplemental beta-carotene has not been shown to have an effect on Alzheimer's disease risk.

Bitter orange: Bitter orange has been used in aromatherapy, although it does not appear to reduce combative, resistive behaviors in individuals with dementia. Currently, evidence supporting the use of bitter orange for dementia and behavioral challenges is lacking.

DHEA: Studies of the effects of dehydroepiandrosterone (DHEA) on memory have produced complex and inconsistent results. Additional study is warranted in this area.

Gingko: The results of limited available study investigating the effect of Ginkgo biloba on post-prandial mental performance are unclear. Ginkgo may benefit some but not all endpoints. Further clinical trials are required before a conclusion can be made.

Psychotherapy: Based on limited available study, brief psychotherapeutic approaches may not help improve cognitive function and overall well-being in Alzheimer's disease patients. More studies are needed in this area.

Diet: Some studies indicate that a largely vegetarian diet high in vitamins and minerals may lower the risk for dementia and Alzheimer's disease. Nevertheless, eating a healthy diet that is low in saturated animal fat and not smoking tobacco can reduce the risk for stroke and other cardiovascular disorders that may lead to dementia.

Lifestyle: Lifestyle habits that can reduce the risk for head injury include using seat belts, wearing a helmet when riding bicycles and motorcycles, and wearing protective headgear when playing contact sports. Avoiding substance abuse and addiction can reduce the risk for dementia resulting from disease, vitamin deficiency, seizure, and head injury. Safer sex practices can help prevent human immunodeficiency virus (HIV) and syphilis infection, reducing the risk for acquired immunodeficiency syndrome (AIDS) dementia complex and neurosyphilis dementia. The risk for dementia as a result of other metabolic or toxic conditions can be reduced by receiving prompt medical attention at the first sign of illness (such as fever, pain, swelling, heat, confusion, or other impairment of cognitive function).

Some of the most recent research indicates that taking steps to improve cardiovascular (heart) health, such as losing weight, exercising, and controlling hypertension (high blood pressure) and high cholesterol, may also help prevent dementia. A clinical study found that individuals with mild to severe Alzheimer's disease placed on a simple exercise program (one hour twice a week) had a significantly slower cognitive decline than those on routine medical care.

Mental fitness: Maintaining mental fitness may delay onset of dementia. Some researchers believe that lifelong mental exercise and learning may promote the growth of additional synapses, the connections between neurons, and delay the onset of dementia.

Non-steroidal anti-inflammatory drugs (NSAIDs): Several clinical studies have reported that the NSAIDs ibuprofen (Advil® or Motrin®), naproxen sodium (Aleve®), and indomethacin (Indocin®, a prescription drug) may reduce the risk of developing Alzheimer's disease (AD). This may be because inflammation appears to play a role in AD. Because NSAIDs can cause gastrointestinal bleeding and kidney problems, clinical trials need to be completed before it's clear whether individuals should take NSAIDs solely to prevent AD.

Statins: Statin drugs are used to lower cholesterol levels. They include atorvastatin (Lipitor®) and simvastatin (Zocor®). Recent studies have reported that they may also reduce the risk of AD. More studies are being done to determine exactly what role, if any, statins may have in Alzheimer's prevention.

Selective estrogen receptor molecules (SERMs): A drug called a selective estrogen receptor molecule (SERM, including raloxifene or Evista®) is used to protect against the bone loss associated with osteoporosis. It also appears to lower the risk of developing mild cognitive impairment, a memory disorder that often precedes AD.

AIDS dementia complex (ADC): AIDS dementia complex (ADC), also known as HIV dementia, HIV encephalopathy, and HIV-associated dementia, is a common brain disorder associated with HIV infection and AIDS. Researchers believe that HIV itself causes ADC, but it is not clear exactly how the virus damages the brain cells. It has been suggested that the HIV proteins may damage nerve cells directly or indirectly.

Many researchers suspect that HIV damages the neurons indirectly. According to some scientists, HIV either infects or activates cells called macrophages and microglia. These cells then produce toxins that can stimulate a series of reactions, which instruct nerve cells (called neurons) to kill themselves. The infected macrophages and microglia also appear to produce proteins called chemokines and cytokines that mediate and regulate immunity, inflammation, and the development of blood cells. These chemokines and cytokines can also affect neurons, as well as astrocytes. The affected astrocytes, which normally protect and nurture neurons, may cause damage to neurons.

Alcoholism: Alcoholism can lead to vitamin B1 (thiamin) deficiency, seizures, and head injuries that produce dementia. Chronic drug abuse, with drugs such as cocaine and heroin, also can cause symptoms of dementia.

Alzheimer's disease: Alzheimer's disease (AD) causes 50-70% of all cases of dementia. AD is the progressive deterioration of areas in the brain essential for learning and memory. Several factors, including age, gender, and lifestyle choices have been associated with AD.

In addition, people with family histories of AD appear to have an increased risk of developing the disease. However, the genetic risk factors associated with the condition remain largely unexplained. Researchers have identified a few genetic mutations that greatly increase the risk in some families. A clear inherited pattern of AD exists in less than 10% of cases.

Early-onset familial Alzheimer's disease has been associated with three predisposition genes: PS1 on chromosome 14, PS2 on chromosome 1, and APP on chromosome 21. These genes affect the production of the amyloid precursor protein and the production of toxic beta-amyloid, creating plaques associated with Alzheimer's disease. Mutations in PS1 account for 30-50% of patients younger than 60 with a strong family history. More than 70 different mutations in the PS1 gene have been reported. All three genes are inherited as autosomal dominant genes. This means that carriers of the genes have a 50% chance of passing their genes to their children.

Up to 20% of pre-senile AD cases are due to the presence of susceptibility genes. Susceptibility genes cause the disease to occur earlier in life than it would without the gene. It is important to note that the mechanism by which this earlier onset occurs is not well understood.

One of the most well-understood genetic risk factors for Alzheimer's disease is the apolipoprotein E (APOE) gene. Mutations in this gene increase the chances of developing late-onset AD. The APOE gene is found in three different forms: APOE 2, APOE 3, and APOE 4. APOE 4 has been associated with an increased risk for developing AD. Unlike the predisposition genes, not all patients with the susceptibility gene APOE 4 will develop AD. Carrying an APOE 4 gene does not predict that a patient will definitely develop AD. Patients with two copies of the APOE 4 gene have a significantly increased risk of developing the condition, and patients with only one copy have a three-fold increased risk compared to the general population. Researchers expect to discover more susceptibility and risk reducing genes.

In addition, nearly all people with Down syndrome who live into their 40s develop AD. Down syndrome is a condition in which extra genetic material causes delays in the way a child develops and often leads to intellectual disabilities.

Amyotrophic lateral sclerosis: Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease, is a progressive neuromuscular disease that weakens and eventually destroys motor neurons. Neurons are components of the nervous system that connect the brain with the skeletal muscles. Most experts believe that ALS does not affect an individual's mental processes. In most people, neither cognitive processes (such as thinking, learning, memory, and speech) nor behavior is affected. Occasionally, however, a person with ALS does experience dementia. Dementia in ALS is thought to be due to destruction of cells in the frontal lobe of the brain. Dementia is rare in ALS. It occurs in all ethnic groups and in both men and women. People aged 55-65 years are most likely to be affected.

Creutzfeldt-Jakob disease: Creutzfeldt-Jakob disease (CJD) is a transmissible, rapidly progressing, neurodegenerative disorder called a spongiform degeneration and is related to "mad cow disease." The initial symptom of CJD is usually a vague personality change, followed within weeks or months by rapidly progressing dementia. The dementia is often accompanied by other central nervous system problems, such as visual disturbances and involuntary jerks of the limbs termed myoclonus.

Huntington's disease: Huntington's disease (HD) is an inherited condition caused by a single abnormal gene. Each child of an HD parent has a 50% chance of inheriting the HD gene. Because signs and symptoms typically appear in middle age, some parents may not know they carry the gene until they have already had children and possibly passed on the trait. If a child does not inherit the HD gene, he or she will not develop the disease and cannot pass it to subsequent generations. In most cases, a person who inherits the HD gene will eventually develop the disease.

Infection: Disease caused by viral, bacterial, or fungal infection can lead to impaired cognitive function. In some cases, appropriate treatment of the underlying condition can reverse symptoms. Infections that may cause dementia-like symptoms include meningitis (inflammation of the membranes that cover the brain and spinal cord) and encephalitis (inflammation of the brain). Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are viral infections that may lead to AIDS dementia complex during late stages of the disease. Antiretroviral therapy has been reported to reduce the incidence of AIDS dementia.

Lewy body dementia: Lewy body dementia is similar to AD, but may progress more rapidly. Abnormal brain cells called cortical Lewy bodies occur throughout the brain and produce symptoms such as a decline in cognitive function and memory loss.

Medications: Prescription and non-prescription drugs that may cause dementia include: anticholinergics, such as hyoscyamine (Levsin®) or tolterodine (Detrol®); barbiturates, such as secobarbital (Seconal®); benzodiazepines, such as alprazolam (Xanax®) and diazepam (Valium®); cough suppressants, such as dextromethorphan; digitalis (Lanoxin®); monoamine oxidase inhibitors, such as phenelzine (Nardil®); and tricyclic antidepressants (TCAs), such as amitriptylline (Elavil®), doxepin (Sinequan®), and imipramine (Tofranil®). These medications are more likely to cause signs of dementia in the elderly than in younger, healthier individuals.

Multi-infarct disease: Multi-infarct disease is the second most common cause of irreversible dementia. In this condition, multiple strokes lead to a progressive decline in cognition. Strokes are neurological damage in the brain due to a lack of oxygen. Multiple infarct dementia is more common in men over 50 years old. A person with this condition may also experience motor weakness, urinary incontinence, and ataxia (irregular muscle coordination) and may develop hypertension, diabetes, or vascular disease.

Neurosyphilis dementia: Neurosyphilis dementia may result from late-stage syphilis. This disease also may cause heart problems, tremors, ataxia (loss of muscle coordination), paralysis, and blindness. Damage may be irreversible.

Parkinson's disease: Several factors, including age, gender, exposure to pesticides and herbicides, reduced estrogen levels, and medications, are thought to play a role in Parkinson's disease. In addition, having one or more close relatives with Parkinson's disease increases the chances that the person will also develop the disease. However, the risk of developing Parkinson's disease is still less than five percent if a relative has the condition.

Pick's disease: Pick's disease is also similar to AD. In most patients, the frontal and temporal lobes of the brain atrophy (partial or complete wasting). This illness usually affects people between the ages of 40-60 years.

Structural abnormalities: Structural abnormalities that can produce dementia include brain tumors located in areas involved with cognitive function, chronic subdural hematoma (blood clot in the brain) resulting from head injury (common in the elderly and alcoholics), hydrocephalus, and normal pressure hydrocephalus. Surgical treatment may relieve symptoms.

Age: The greatest risk factor for dementia is advanced age. Dementia is considered a late-life disease because it tends to develop mostly in elderly people. About five to eight percent of all people over the age of 65 have some form of dementia; this number doubles every five years above that age. It is estimated that as many as half of people in their 80s suffer from dementia. Research has determined that a decline in cerebral glucosemetabolism commonly found in advanced aging may be a risk factor in the development of dementia.

Heredity: The risk of developing dementia, such as dementia associated with Alzheimer's disease or Huntington's disease, appears to be slightly higher if a first-degree relative (a parent, sister, or brother) has the disease.

Trauma: Trauma to the brain can result in damage to brain cells, leading to dementia. Brain trauma can result from accidents (such as motor vehicle wrecks and falls), assaults (such as gunshot wounds or beatings), or from sports activities (such as boxing) without protective gear. Dementia caused as a result of trauma can be permanent or temporary, depending on the extent of damage and the ability of the individual's body to recover.

Infections: Infections of brain structures, such as meningitis (inflammation of the protective membranes in the brain) and encephalitis (inflammation of the brain), are primary causes of dementia. Other infections, such as human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) and syphilis (a bacterial sexually transmitted disease), can affect the brain in later stages. In all cases, inflammation in the brain damages cells. Damage to memory due to infection can be permanent or temporary, depending upon the extent of the damage and the ability of the individual's body to recover.

Normal pressure hydrocephalus: The brain floats in a clear fluid called cerebrospinal fluid. This fluid also fills internal spaces in the brain called ventricles. If too much fluid collects outside of the brain, it causes a condition known as hydrocephalus. This condition raises the fluid pressure inside the skull and compresses brain tissue from outside. It may cause severe damage and death. If fluid builds up in the ventricles (four communicating cavities filled with cerebrospinal fluid in the brain), the fluid pressure remains normal. This condition is known as normal pressure hydrocephalus, but it causes brain tissue to be compressed from within. The compression on the brain from the fluid build up causes a decrease in the delivery of oxygen to brain tissues, thus causing damage that can lead to permanent or temporary dementia.

Simple hydrocephalus: Simple hydrocephalus may cause typical dementia symptoms or lead to coma. The difference in simple hydrocephalus and normal pressure hydrocephalus is that individuals have trouble walking and become incontinent (unable to control urination) at the same time they start to lose mental functions, such as memory, in simple hydrocephalus. If normal pressure hydrocephalus is diagnosed early, the internal fluid pressure may be lowered by the placement of a shunt. A shunt is a medical device that helps drain excess cerebrospinal fluid from the ventricles, decreasing pressure. This can stop the dementia, gait (pattern of walking) problems, and the incontinence from becoming severe.

Brain tumors: Tumors can contribute to signs and symptoms of dementia in a number of ways. A tumor can press on structures that control hormone secretion in the brain, such as the hypothalamus or pituitary gland. Tumors can also press directly on brain cells, damaging them and causing cell death. Treating the tumor, with chemotherapy, radiation, or surgery, may reverse the symptoms in some cases.

Toxic exposure: Individuals exposed to toxic chemicals, such as those who pave roads or paint cars, especially without adequate protective equipment and ventilation, may develop dementia from the damage these substances can cause to brain cells. Some toxic exposures may be treatable and avoiding further exposure can prevent further damage.

Metabolic disorders: Diseases of the liver, pancreas, or kidneys can lead to dementia by disrupting the balances of substances in the blood, including minerals, vitamins, and sugars. Often, these changes occur rapidly and affect the individual's level of alertness and consciousness. This is called delirium. Although the individual with delirium, like the one with dementia, cannot think well or remember, treatment of the underlying disease may fully reverse the condition. If the underlying disease persists, however, brain cells may die and the individual may develop dementia.

Hormone disorders: Disorders of hormone-secreting and hormone-regulating organs, such as the thyroid gland, the parathyroid glands, the pituitary gland, or the adrenal glands, can lead to hormone imbalances. These imbalances may lead to dementia if not corrected with hormonal supplementation in the form of drugs and supplements.

Hypoxia: Hypoxia is a lack of oxygen in the body. Individuals who do not have enough oxygen in their blood may develop dementia because the blood brings oxygen to the brain cells. Brains cells need oxygen to survive. The most common causes of hypoxia are lung diseases, such as emphysema or pneumonia. These limit oxygen intake or transfer of oxygen from the airways of the lungs to the blood. Cigarette smoking is a frequent cause of emphysema. Smoking can increase hypoxic brain damage by damaging the lungs and also by increasing the levels of carbon monoxide in the blood. Heart disease leading to congestive heart failure may also lower the amount of oxygen in the blood. Sudden, severe hypoxia may also cause brain damage and symptoms of dementia. Sudden hypoxia may occur if an individual is comatose or has to be resuscitated. Vascular dementia, or dementia as a result of a lack of blood flow to the brain, can be caused by anemia. Anemia is the decreased capacity of red blood cells to carry oxygen to the body's tissues. This results in cell death, such as in the brain, causing temporary or permanent dementia.

Drugs: Some prescription and non-prescription drugs can cause temporary problems with memory and concentration as side effects, mainly in the elderly. Misuse or abuse of medications chronically (long-term), whether intentional or accidental, may lead to dementia. Illegal drugs, such as cocaine and heroin, may also lead to signs and symptoms of dementia.

Nutritional deficiencies: Deficiencies of certain nutrients, especially the B vitamins, may lead to dementia if not corrected. Homocysteine levels in the body are increased with vitamin deficiencies including folic acid, vitamin B1 (thiamin), and vitamin B12 (cyanocobalamin). Homocysteine is an amino acid, which helps build proteins in the body. An elevated homocysteine level is thought to be a risk factor for developing dementia along with increasing the risk of developing heart disease. Iron deficiency may lead to anemia, which can lead to brain cell death and eventually dementia.

Chronic alcoholism: Dementia in individuals with chronic (long-term) alcoholism is believed to be a result of other complications such as liver disease and nutritional deficiencies.

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.